Continued from Part I and from Part II.
Prehospital RN responded with –
There is also a lot more to the question that just “Epi vs. No Epi” …
All drugs, even the relatively safe ones and yes, even oxygen, are toxic if given in high enough doses … when some is good, more is not always better. In other words, a patient may benefit from a specific dose of a drug, but if you double or triple or multiply the dose by ten, more than likely you will end up harming the patient rather than helping him.
Exactly.
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The doses of epinephrine given during cardiac arrest are massive, and even a single round of epi isn’t something that would be very well tolerated by a living, perfusing patient. But is there maybe a middle ground, possibly a lower dose given by infusion, that might help produce ROSC without all the toxicity and lead to increased survival? There is no way to know until a lot more research is done … and that won’t happen until we cut through a lot more bureaucratic red tape.
We presume that a larger dose is needed to have an effect on a dead person, but this ignores the obvious.
If it works, then we have a huge dose in a living unstable patient. This dose is one that would be considered an extreme drug dosing error if we were to give the same dose to the same patient just after ROSC, rather than just before ROSC. We may even be giving these doses to living patients, since we do not check for ROSC between delivering a shock and delivering a drug.
Which is more likely to produce ROSC, the shock or the drug?
The shock, so why do we ignore the likelihood that we will be giving cardiac arrest doses of epinephrine to living patients by following the current ACLS guidelines?
We are giving epinephrine to Schrodinger’s cat.
Image from http://manan.posterous.com
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Will epinephrine reverse the condition of Schrodinger’s cat?
Will epinephrine kill a living cat, but resuscitate a dead cat?
Why would we want to kill a cat we have successfully resuscitated?
Should our actions be so cavalier with human patients?
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“We are giving epinephrine to Schrodinger’s cat.”
That needs to go on a t-shirt.
Ben,
I like that idea. I will have to take that up with the Rogue Medic marketing division. 🙂
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Hey Rogue,
Have you come across the PACA trial from Western Australia? Would like to hear your take on this bit of research: http://circ.ahajournals.org/cgi/content/meeting_abstract/122/21_MeetingAbstracts/A1
Flo,
I wrote about this study recently in Bogus Ethics and Epinephrine in Cardiac Arrest.
Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial
Ian G. Jacobs, Judith C. Finn, George A. Jelinek, Harry F. Oxer, Peter L. Thompson
Resuscitation. Received 19 June 2011; received in revised form 22 June 2011; accepted 24 June 2011. published online 04 July 2011.
Uncorrected Proof
Abstract from Resuscitation
When I wrote the original post, the full text was available for free, but now it asks me to register.
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Sorry Rogue, missed that. Admittedly on night shift when I read it…